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Claiming from Your Medical Aid Should Not Be a Hassle


The vast majority of South Africans who enjoy private healthcare would be totally unable to meet the cost of private treatment if they did not receive some form of financial support for this purpose. Young and single citizens with good general health, may be concerned only with meeting the cost of an unexpected emergency, and might choose to purchase cover that applies only when hospitalised. However, those who are older and have families to support will generally want more comprehensive cover. However, regardless of how much or how little cover you may choose, in an ideal world, claiming from your medical aid should never be a problem.

Sadly, the real world is far from ideal, so this is not always the case. Much of the time, it is a member’s failure to understand the terms and conditions concealed in the small print that is the root of the problems commonly experienced by claimants. For example, because service providers are at liberty to set their own fees within certain limits, the amount agreed by a fund as the limit for a given procedure may fall short of the fee levied by the service provider. In such cases, the shortfall between the actual cost and the maximum sum agreed will be for the account of the member. Known as co-payments, these should not cause problems, providing you are aware of this possibility when claiming from your medical aid.

Other confusions arise as a result of limits. There may, for example, be an annual limit on the total amount of cover available for routine dentistry. In other cases, such as when cover for a new main or dependent member with a pre-existing condition is withheld during an initial waiting period. Once again, providing such conditions are clearly stated and displayed prominently in a member’s documentation, this should not result in any unpleasant surprises. One thing everyone needs to be aware of is that, whether you are a new main or new dependent member, there will be no point in claiming prescribed minimum benefits from your medical aid until the legally-permitted 90-day waiting period has expired.

To a degree, just how the remuneration process operates is also up to the requirements of the service provider. Many require an up-front payment from their patients who must then apply to the appropriate fund for reimbursement. In other instances, however, the member may have no need to become involved in the claims process at all. Some service providers choose to undertake this process on behalf of their patients as and when it becomes necessary. Where this is the case, you remain responsible for any co-payment that might apply whilst relieved of all responsibility for claiming a refund from your medical aid.

While the role played in South Africa by these non-profit organisations is invaluable, they are still businesses that require members to continue operating, often promoting membership with incentives that must be paid for, either by increased premiums or reduced cover. At KeyHealth, the policies of total transparency, simple understandable terms, and focussing on core benefits ensure exceptional value for money. Furthermore, with the option of uploading, emailing, and submission via a mobile app or the post, claiming from your medical aid could not be easier.